WVNA Student Member Honor Cord Program

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* 1. First Name

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* 2. Last Name

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* 3. E-mail

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* 4. Phone

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* 5. Mailing Address

Street

City

State

Zip

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* 6. Graduation Date

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* 7. School of Nursing

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* 8. Required Assignment Details (must have four credits).

Attended WVNA Policy Summit Dinner (2 Credits)

Attended WVNA Nurses' Day at the Capitol (2 credits)

WVNA Student Subscriber (1 Credit)

Attended WVNA Legislative Leader Training & WVNA Legislative Preview (1 Credit)

Attended WVNA Legislative Updates (1 Credit)

Attended WVNA Legislative Wrap-up (1 Credit)

Other (please specify)

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* 9. Faculty advisor:

Name

School of Nursing

Email Address

Phone Number

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* 10. CERTIFICATION:
I affirm that the information provided is complete, accurate, and true to the best of my knowledge.

Name:

Date:

WVNA Student Member Honor Cord Program

Question Title

* 1. First Name

Question Title

* 2. Last Name

Question Title

* 3. E-mail

Question Title

* 4. Phone

Question Title

* 5. Mailing Address

Question Title

* 6. Graduation Date

Question Title

* 7. School of Nursing

Question Title

* 8. Required Assignment Details (must have four credits).

Question Title

* 9. Faculty advisor:

Question Title

* 10. CERTIFICATION: I affirm that the information provided is complete, accurate, and true to the best of my knowledge.

* 10. CERTIFICATION:
I affirm that the information provided is complete, accurate, and true to the best of my knowledge.